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. <br /> Statement of Organization ' • ' ' , � <br /> Recipient Committee ' • � <br /> INSTftUCTiONS ON REVERSE � Page3 <br /> I.D.NUMBER <br /> COMMITTEE NAME <br /> Committee to elect Janet Borgens 1374422 <br /> a Type;of Corrir�lt�e;��� ��l�an�n�,�a) 3:,� <br /> • • • �� • � Not formed to support or oppose specific candidates or measures in a single election. Check oniy one box: <br /> ❑ CITY Committee ❑ COUNTY Committee❑ STATE Committee <br /> PROVIDE BRIEF DESCRIPTION OF ACTIVITY <br /> .: . -. . List additional sponsors on an attachment. <br /> NAME OF SPONSOR INDUSTRY GROUP OR AFfILIATION OF SPONSOR . <br /> STREET A�DRE55 NO.AND STREET CITV STATE ZIP CODE <br /> � � � � ��� <br /> Uate qual(fied <br /> ���.,. . �.�� ..:....... . .. .� ;,, . ,:, :�. , . �. , , .. . . . <br /> � ' �.:> "" ve�i �aHorr. e treas�rer assis ant:ir asurer and/or candidate,offlCehalder,or proponent certity.that all of#he foQowingcondltions have 6een met; <br /> S Terminat��t�aR�.t�,tti��s�n�s w.����s��g+�� fi� i� _ , . _ -_ :: : <br /> _,.... ._� , e ., . <br /> � �a��, ,,f .��t s,.��F,.,_t�_ a�.� ,� .�. <br /> • This committee has ceased to receive contributions and make expenditures; � <br /> • This committee does not anticipate receiving contributions or making expenditures in the future; <br /> • This committee has eliminated or has no intention or ability to discharge all debts,Ioans received,and other obligations; <br /> • This committee has no surplus funds;and <br /> • This committee has filed all campaign statements required by the Political Reform Act disclosing all reportable transactions. <br /> -- There are restrictions on the disposidon of surplus campaign funds held by elected officers who are leaving office and by defeated candidates. Refer to Government <br /> Code Section 89519. <br /> -- Leftover funds of ballot measure committees may be used for polifical,legislative or governmental purposes under Government Code Secfions 89511-89518,and are <br /> subject to Elections Code Section 18680 and FPPC Regulation 18521.5. <br /> FPPC form 410(Dec/2012) <br /> FPPC Advice:advice@fppc.ca.gov(866/275-3772) <br /> .. www.fppc.ca.gov <br />